EXPERT REACTION: Mental health screening "critical" for chronic pain treatment

Chronic pain is common – 20 – 30% of the population are estimated to live with chronic/persistent pain, this means in New Zealand probably over one million people live with pain, disproportionately affecting women, Māori, and people with disabilities.

"Most people with pain are seen in primary care, but those with high impact chronic/persistent pain (pain that significantly impacts the person’s daily life and functioning) are more likely to have comorbid depression and anxiety and need specialised services. Specialist pain services bring different professionals together to provide whole-person care, spanning both physical and psychosocial aspects of chronic pain. In 2024, Health New Zealand/Te Whatu Ora indicated that 3,451 people received an initial appointment with a specialist pain service. This is less than 1% of the estimated 362,000 people living in New Zealand with high impact pain.

"Treatments for the most common types of chronic/persistent pain (e.g., fibromyalgia, chronic low back pain) have limited impact on pain intensity, meaning many people will live with their pain long-term. Supported self-management alongside peer support is needed. These skills take time and support to develop but  reduce the burden on health services.

"Therapies such as Acceptance and Commitment Therapy are effective for people with comorbid chronic  pain and mental health problems. This approach is used by Health Improvement Practitioners (HIPs)  working in primary care. HIPs often come from occupational therapy, nursing, and social work backgrounds but need additional training in chronic pain management. This workforce could provide screening and early intervention for those with chronic pain and reduce the burden on psychologists. With the support of specialist pain services, and integration of peer support, this approach could help reduce the existing unmet  need for chronic pain management services.

It’s not surprising to see a high rate of depression and anxiety amongst people with chronic pain. Living with chronic pain can affect many aspects of a person’s life, making it challenging and frustrating to do everyday tasks, to enjoy social relationships, to work and thrive. People with chronic pain can also experience stigma, where others don’t take their pain seriously or they may even feel disbelieved or judged for their pain. So it’s not just the pain itself but the effects it has on a person’s life that mean that chronic pain can lead to both anxiety and depression. Also, depression and anxiety influence the way the body’s nervous system responds to painful experiences, so the two problems can become a vicious cycle.

"It’s imperative the people with chronic pain and their whānau receive integrated support that addresses the physical, psychological, social and spiritual aspects of managing pain. Unfortunately in Aotearoa, we have few multidisciplinary pain clinics able to provide this support, and those that exist usually have long waiting lists. Many are adult services which don’t treat children or young people. Chronic pain affects upwards of 20% of the population and huge costs to society, so this should be a health priority.

The comprehensive systematic review of prevalence studies identified clinically significant depression and anxiety in 40% of people with chronic pain (excluding chronic headache or migraine). Young adults, women and those with primary pain conditions due to a sensitised nervous system (e.g. fibromyalgia) were more likely to experience depression and anxiety.

"Chronic pain is a major public health burden in Aotearoa New Zealand affecting one in five New Zealanders. Women, Māori and those living in areas of high deprivation are at more risk of reporting chronic pain.(1) The study substantiates a common clinical finding that chronic pain is associated with depression and anxiety in a significant proportion of people (40%) and the stigma associated with it. A New Zealand-based study has found co-occuring mental health conditions (depression or anxiety) was one of the strongest predictors to experience greater stigma, which in turn could lead to further disability, social isolation and depression.(2) It also highlights the holistic impact of chronic pain on psychological and emotional wellbeing (hinengaro) of the individual living with chronic pain and the need for explain themselves due to the invisible nature of pain and unclear clinical investigations. While multidisciplinary pain clinics often assess for co-occurring depression and anxiety in chronic pain patients, this study underscores the importance of identifying people who may be at more risk of reporting depression and anxiety (i.e. young adults, women and those with widespread pain conditions (e.g. fibromyalgia) and provide tailored support. The study findings strongly support the need for holistic mind-body focused treatment approaches supporting people with chronic pain.

"There is, however, a shortage of trained pain professionals in Aotearoa New Zealand providing such mind-body focused treatment approaches, which further adds to the emotional burden in seeking pain care. Overall, the study findings point out to the importance of acknowledging chronic primary pain as a long-term condition in its own right.(3) Acknowledging and validating the holistic impact of pain on the psychological and emotional wellbeing (hinengaro) of the individual and their whānau could help people listened to and mitigate feelings of stigma, which could ultimately support them to live well despite chronic pain."

References
1. New Zealand Ministry of Health. Annual Update of Key Results 2019/20: New Zealand Health Survey. In: New Zealand Ministry of  Health, ed: New Zealand Ministry of Health,; 2024.
2. Bean DJ, Dryland A, Rashid U, Tuck NL. The determinants and effects of chronic pain stigma: A mixed methods study and the development of a model. J Pain. 2022.
3. Kang Y, Trewern L, Jackman J, McCartney D, Soni A. Chronic pain: definitions and diagnosis. BMJ. 2023;381.

Chronic pain is a very common and debilitating condition, affecting approximately one in five New Zealanders. This research confirms what many people living with chronic pain already know, that there is a strong connection between pain and emotional well-being. We now have strong scientific evidence that people with chronic pain are significantly more likely to experience depression and anxiety. Experiencing depression or anxiety alongside chronic pain is a common and understandable reaction. It's not a personal failing, but a natural response to ongoing suffering. We should encourage open conversations about the emotional challenges of living with chronic pain, so people feel comfortable seeking help.

"This research highlights the need for a holistic approach to treatment. It is very important that health professionals assess and treat the whole person, not just the pain condition. This means that systematic screening for depression and anxiety and appropriate referral to mental health professionals should be a routine part of care for people with chronic pain. However, this is often challenging in the New Zealand health system.

"Interdisciplinary pain services, which include psychologists or other mental health professionals, remain the gold standard treatment for chronic pain. Unfortunately, despite their proven, cost-effective outcomes, interdisciplinary pain services have been woefully underfunded in New Zealand for decades – large disparities in access remain, particularly away from the main centres, and waiting times to be seen frequently exceed three to six months.